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Liver cirrhosis (LC) is a common disease diagnosed in all ages. With the increasing population age, LC is noticeable more in the clinics.To distinguish the clinical characteristics, complications, and survival of patients with liver cirrhosis.A retrospective study enrolled patients diagnosed with liver cirrhosis at Soroka University Medical Center. Patients with cirrhosis diagnosed at an age older than 65 years (group 1) were compared with patients diagnosed at an age younger than 65 years (group 2).We included 1046 patients; 411 (39.3%) in group 1 and 635 (60.7%) in group 2. Fatty liver and cryptogenic liver disease were found to cause cirrhosis at a significantly higher rate in the elderly (23.4% vs. 13.9%, p 0.001, 15.3% vs. 6.3%, p 0.001, respectively). A higher rate of non-hepatocellular carcinoma cancers and mortality (17.5% vs. 9.1%, p 0.001, 76.6% vs. 57%, respectively) was found among cirrhotic elderly patients, but a lower rate of oesophageal varices (47.7% vs. 60.1%, p = 0.002). Twenty-year follow-up Kaplan-Meier survival analysis for mortality estimated poor survival in the elderly (log-rank p 0.001). The adjusted Cox proportional hazards regression model showed an association of age 65 with an all-cause mortality hazard ratio of 2.26 (95% CI 1.89-2.69).Higher rates of fatty liver, cryptogenic cirrhosis, non-HCC cancers, and mortality were found among patients diagnosed with cirrhosis in the elderly.

PURPOSE: To compare the clinical and tomographic properties of adult patients with keratoconus treated with accelerated corneal cross-linking (A-CXL) versus accelerated contact lens–assisted corneal cross-linking (A-CACXL). METHODS: Patients who underwent A-CXL and A-CACXL due to progressive keratoconus were enrolled from January 2015 to January 2018 in this retrospective case–control study. The treatment group (minimum corneal thickness of less than 400 µm after epithelium removal; 30 patients, 30 eyes) was treated with A-CACXL; the control group (minimum corneal thickness of 400 µm or greater, 32 patients, 32 eyes) was treated with A-CXL. Assessments occurred before treatment and 12 months postoperatively. Demographic, clinical, and tomographic data were obtained from outpatient clinic reports. RESULTS: Significant improvement in visual acuity was evident at 12-month follow-up for the control group in uncorrected distance visual acuity (0.62 ± 0.42 vs 0.43 ± 0.31 logMAR, P = .01) and the treatment group in corrected distance visual acuity (0.51 ± 0.30 vs 0.40 ± 0.49 logMAR, P = .03). Progression of keratoconus was halted at similar rates for both groups (76.7% treatment, 84.4% control, P = .21). Mean minimum corneal thickness showed minor but significant thinning at the 12-month follow-up visit compared to baseline (control group = 463 ± 31 vs 450 ± 35 µm, P > .01; treatment group = 398 ± 32 vs 388 ± 41 µm, P = .02). CONCLUSIONS: A-CACXL halted keratoconus progression in 76.7% of eyes and achieved regression in 33.3% of eyes, with rates comparable to A-CXL. Visual outcomes improved for both groups, with similar keratometry changes. A-CACXL is an effective and safe option for patients with keratoconus and thin corneas, with results similar to A-CXL treatment in patients with a minimum corneal thickness of 400 µm or greater. [ J Refract Surg . 2021;37(9):623–630.]

We aimed to assess the incidence, clinical and biochemical course of immunotherapy-induced thyroiditis and its implication on patients' survival, based on an extensive clinical experience from a tertiary cancer center.Analyses were based on data from the electronic medical records of cancer patients treated with CPIs. Data included demographic characteristics, cancer type, Thyroid function tests (TFT), and survival.Thyroid function tests were available for 934 patients. After excluding patients with impaired baseline TFT or levothyroxine treatment, 754 euthyroid patients were included in the core analyses. Of those, 301 (39.9%) patients developed thyroid dysfunction ('thyroiditis'). Thyroiditis was more prevalent in patients with renal cell carcinoma than other types of cancer. Survival rates were comparable in patients who developed thyroiditis and in those who did not. during the 5 years follow-up period, there was a non-significant trend toward improved survival in patients who developed TD in four predefined groups: melanoma, lung cancer, renal cell carcinoma, and transitional cell carcinoma. Nevertheless, we observed a highly significant survival benefit for patients with renal cell carcinoma who developed TD (HR = 0.19, 95% CI 0.06-0.60;Thyroiditis is common, often asymptomatic, and is more prevalent in patients treated with combinations of nivolumab and PD-L1 inhibitors, and in patients with renal cell carcinoma. Thyroiditis was associated with a trend for a survival benefit, particularly in patients with renal cell carcinoma.

To examine the association between exposure to radiation from computed tomography (CT) studies and the incidence of cataract. In a nested case–control study, all cataract cases and their matched controls were sampled from a retrospective cohort of Israeli residents who underwent CT scans or ultrasonic tests in Soroka Medical Center, Beer-Sheva, Israel, between the years 1996 and 2014. The risk of cataract associated with head, neck or the rest of the body CT was assessed using Poisson survival analysis. The nested matched sample included 3841 cataract cases and their age- and sex-matched controls (n = 228,743). CT radiation exposure was more frequent in the cataract group, with 9.7% head CT, 1.2% neck CT and 6.6% other CT, compared to 5%, 0.7% and 3.7% among person-years without cataract (p

PURPOSE: To compare the outcomes of accelerated photoactivated chromophore for keratitis corneal cross-linking (PACK-CXL) as an adjunct treatment for bacterial keratitis (PACK-CXL plus standard antibiotic therapy) for patients receiving only standard antibiotic therapy. METHODS: Retrospective cohort study of outcomes of patients with moderate infectious presumed bacterial keratitis (ulcer diameter 2 to 7 mm and stromal depth < 300 µm) were compared before and after initiation of a new treatment protocol of PACK-CXL in addition to standard antibiotic treatment. RESULTS: A total of 70 eyes of 70 patients were included: 39 eyes in the PACK-CXL plus antibiotic (PACK-ABX) group and 31 eyes in the antibiotic only (ABX) control group. The PACK-ABX group showed shorter times to complete reepithelialization (9.3 ± 6.0 vs 16.0 ± 12.7 days, P = .01) and did not require tectonic emergency keratoplasty (0% versus 19.4%, P = .006). The PACK-ABX group also showed a higher percentage of eyes with complete reepithelialization in 6 days or less (46.2% vs 6.5%, P < .001) and a trend for shorter hospitalizations (6.3 ± 5.0 vs 8.5 ± 4.5 days, P = .06). A multivariate analysis controlling for age showed that PACK-ABX treatment remained significantly associated with early ulcer reepithelialization (odds ratio = 0.09, 95% confidence interval = 0.02 to 0.48, P = .005). CONCLUSIONS: This study validates previous findings regarding the use of accelerated PACK-CXL in the treatment of bacterial keratitis. Adding PACK-CXL improved clinical outcomes (reducing healing time) when compared to antibiotics alone. [ J Refract Surg . 2020;36(4):258–264.]

Objective: Serum calcium levels often decrease during acute illness in patients with an intact calcium-regulating system. However, the dynamics of serum calcium levels in hospitalized pati...

Cardiac surgery and cardiopulmonary bypass (CPB) are associated with a systemic inflammatory reaction that occasionally induces a life-threatening organ dysfunction caused by the dysregulated host response to the damage-associated molecular patterns (DAMPs). In severe inflammation, cell-free DNA (cfDNA) and histones are released by inflammatory cells and damaged tissue and act as DAMPs. We sought to characterize the changes in circulating cell-free DNA (cfDNA) levels during CPB. Primary outcomes were renal failure, ventilation time (>18 hr), length of stay (LOS) in the intensive care unit (ICU) (>48hr), hospital LOS (>15 days), and death. We looked for associations with blood tests and comparison to standard scores. In a prospective cohort study, we enrolled 71 patients undergoing non-emergent coronary artery bypass grafting. Blood was drawn at baseline, 20 and 40 minutes on CPB, after cross-clamp removal, and 30 minutes after chest closure. cfDNA was measured by our fast fluorescent method. Baseline cfDNA levels [796 (656–1063) ng/ml] increased during surgery, peaked after cross-clamp removal [2403 (1981–3357) ng/ml] and returned to baseline at recovery. The difference in cfDNA from 20 to 40 minutes on CPB (ΔcfDNA 40–20) inversely correlated with peripheral vascular disease (PVD), longer ventilation time, and longer ICU and hospital length of stay (LOS). Receiver operating characteristic (ROC) curve of ΔcfDNA 40–20 for long ICU-LOS (>48hr) was with an area under the curve (AUC) of 0.738 (p = 0.022). ROC AUC of ΔcfDNA 40–20 to long Hospital LOS (>15 days) was 0.787 (p = 0.006). Correction for time on CPB in a multivariate logistic regression model improved ROC-AUC to 0.854 (p = 0.003) and suggests that ΔcfDNA 40–20 is an independent risk factor. To conclude, of measured parameters, including STS and Euroscore, the predictive power of ΔcfDNA 40–20 was the highest. Thus, measurement of ΔcfDNA 40–20 may enable early monitoring of patients at higher risk. Further studies on the mechanism behind the negative association of ΔcfDNA 40–20 with PVD and outcomes are warranted.

Liver cirrhosis (LC) is a common disease with varied primary causes and ethnic disparities. Clinical characteristics and outcomes of Arab Bedouin (AB) and Jewish patients with LC were retrospective collected and compared. We included 1048 patients, 95 (9%) Arab Bedouin and 953 (91%) Jewish patients. The incidence of cirrhosis was much lower among AB. Age at diagnosis was 47 ± 18 years among Bedouins compared to 61 ± 13 years (p

Pain is a subjective and multidimensional experience often inadequately managed following surgery. Postoperative pain has been shown to correlate with hospital length of stay (HLOS) and hospital complications. Given advancements in preemptive pain management approaches, reevaluation is necessary.The purpose of this study was to examine the association between postoperative pain intensity and HLOS and in-hospital complications among patients who underwent colorectal surgery, adjusted by sociodemographic and underlying medical variables.We used electronic medical records. Data were collected from patients who underwent colorectal surgery at a large general hospital in Israel from January 2012 to December 2018.This is a retrospective cohort study. Information on HLOS, medical diagnoses, pain intensity, use of analgesics, postoperative infections, patient sociodemographic data, chronic diseases, functionality status, and source of admission were extracted from medical records. Logistic regression analysis was used for the final model, and HLOS and in-hospital complications were the major outcomes.We enrolled 1,073 patients. Of them, 554 males (51.6%) with a mean age of 62.54 ± 16.55 years. The median postoperative pain score was 1.54 (interquartile range, 0.84; 2.16), and an in-hospital complication rate of 1.3% (n = 14). Postoperative pain was not associated with prolonged HLOS with adjustment to relevant independent variables (odds ratio, 1.399; 95% confidence interval, 0.759-2.578; p = .282). Contrarily, age, malignancy, assistance needed in activities of daily living, use of analgesic agents, and postoperative infection were risk factors for prolonged HLOS. Additionally, postoperative pain was not related to a higher risk of in-hospital complications.Pain intensity post colorectal surgery was not a risk factor for extended HLOS or in-hospital complications. In contradistinction, tending to patient needs, adequate analgesic use, and reducing infection rates can shorten HLOS, improve health outcomes, and economize health care resources.

Objective: to estimate the association between preoperative hemoglobin A1c (HbA1c) levels below and above 7%, and the rate of all-cause mortality (ACM) in diabetes mellitus (DM) patients after coronary artery bypass grafting (CABG) within a ten-year follow-up period. Methods: we collected data on patient HbA1c levels that were measured up to 3 months prior to isolated CABG in consecutive patients with DM, and analyzed the rates of ACM over a median of a 5.9-year post-operative period. Results: preoperative HbA1c levels were collected in 579 DM patients. The mean HbA1c was 8.0 ± 1.7%, where 206 (35.6%) patients had an HbA1c ≤ 7% and 373 (64.4%) had an HbA1c &gt, 7%. During the follow-up period, mortality rates were 20.4% and 28.7% in the HbA1c ≤ 7% and HbA1c &gt, 7% groups, respectively (Kaplan-Meier estimates, log-rank p = 0.01). Multivariable Cox proportional hazards regression, adjusted for age, gender, smoking status, chronic obstructive pulmonary disease, hypertension, chronic renal failure, old myocardial infarction, number of coronary artery bypass surgeries, and post-operative glycemic control, showed a hazard ratio of 2.67 for long-term ACM (p = 0.001) in patients with HbA1c &gt, 7%. Conclusions: DM patients with high HbA1c levels prior to CABG are at higher risk for long-term complications, especially late ACM.

Objective: To examine the relationship between Intra-operative hyperthermia (IOH) and post-operative fever (POF) and local complications in children undergoing CI surgery. Study Design: Retrospective cohort study Setting: Tertiary care University Hospital. Participants: The study includes all pediatric CI surgery procedures conducted in one hospital in Israel between 2007 and 2017, A total of 213 CI procedures were performed on 191 children (ages 9 months to 17 years; mean 3.54 years) Main outcome and measure: Clinical data included demographics, type of surgery (unilateral, bilateral), presence of IOH and POF, and local infectious complications within one month after surgery Results: Ten patients (4.9%) developed IOH, of which two developed POF. Of the remaining non-IOH cases (95.1%), 29 children (14.3%) developed POF. IOH correlated with cases of bilateral CI (80% bilateral CI versus 20% unilateral CI; p = 0.002). IOH also correlated with the duration of operation (289 min versus 189 min, respectively; p = 0.025). Local complications were recorded in 30 patients: two that developed POF in the IOH group, and 28 (14.3%) in the non-IOH group. No correlation was observed between the occurrence of either IOH or POF, and the occurrence of local complications. Conclusions: IOH and POF are not uncommon in children undergoing CI surgery, yet, in the present study cohort, both conditions are not associated with the development of local infectious complications. In addition, IOH does not appear to predict the development of POF.

AimTo describe ocular manifestations in children with congenital insensitivity to pain with and without anhidrosis (CIPA and CIP).MethodsWe reviewed records of eye examinations of 39 children diagnosed with CIPA or CIP. We collected clinical data, with particular attention to ocular surface findings. Corneal sensitivity was tested by presence of a blink reflex upon touching the cornea. Statistical analysis assessed differences in manifestations between the two conditions, and relationships among corneal sensitivity, presence of corneal opacities and visual acuity (VA).ResultsCIPA was diagnosed in 32 children and CIP in 7. The median follow-up periods were 50 months (CIPA group) and 94 months (CIP group). Corneal opacities were present in 23% of CIPA eyes and in 57% of CIP eyes. A blink reflex was positive in 52% of CIPA eyes and in 33% of CIP eyes. We recorded VA ≥20/25 in 36% of CIPA eyes, whereas all patients with CIP had VA ≤20/30. For the whole cohort, we found a negative correlation between a preserved blink reflex and the presence of corneal opacities, and a positive correlation between a preserved blink reflex and VA ≥20/25.ConclusionChildren with congenital insensitivity to pain are prone to develop corneal scarring. Patients with CIP tend to have more severe ocular surface disease than those with CIPA, probably due to more prevalent loss of corneal sensation. In both groups, a preserved blink reflex correlated with good vision. Affected children should have close follow-up to promptly treat ocular surface disease and prevent vision loss.

Adherence to treatment of chronic Hepatitis B Virus (HBV) is an important issue and can affect the complication rate. Nucleos(t)ide analogue as oral treatments are used for patients with necro-inflammatory activity and high viral load, with the goal of decline the complication rate such cirrhosis and hepatic cancer. We aimed to investigate the adherence to chronic HBV treatment. Chronic HBV patients with dispensing medication rates (DMR) of at least 80% were defined as high adherence group (HAG) and those who dispensed less than 80% as low adherence group (LAG). The study included 273 patients. 90 patients (33%) were in the LAG and 183 (67%) in the HAG. The All-cause mortality in the LAG was 15.6%, and 8.7% among the HAG (p-value = 0.09). 185 patients were of Jewish origin (mean age of 52.96 &plusmn, 14.6 years, 30% women) and 88 patients of Arab Bedouin (AB) origin (mean age of 40.86 &plusmn, 13.96 years (p-value &lt, 0.001), 42% women). The proportion of Jewish patients with high adherence was 71% (131 patients) versus 59% (52 patients) in AB patients (p-value = 0.054). The all-causes mortality was 14.6% among Jewish origin and 3.4% of AB (p-value = 0.01). We conclude that, two third of HBV carriers are with high level adherence to treatment in southern Israel, with lower but marginally significant all-cause mortality. No-significant differences in adherence patterns were noted between Arab Bedouin and Jews.

To examine the association between exposure to radiation from computed tomography (CT) studies and the incidence of cataract.In a nested case-control study, all cataract cases and their matched controls were sampled from a retrospective cohort of Israeli residents who underwent CT scans or ultrasonic tests in Soroka Medical Center, Beer-Sheva, Israel, between the years 1996 and 2014. The risk of cataract associated with head, neck or the rest of the body CT was assessed using Poisson survival analysis.The nested matched sample included 3841 cataract cases and their age- and sex-matched controls (n = 228,743). CT radiation exposure was more frequent in the cataract group, with 9.7% head CT, 1.2% neck CT and 6.6% other CT, compared to 5%, 0.7% and 3.7% among person-years without cataract (p 0.001). In a multivariate analysis, a similar increased risk of cataract associated with head (hazard ratio (HR): 1.24, 95% confidence interval (CI): 1.11; 1.38) and other CT (HR: 1.25, 95% CI: 1.10; 1.43) was found. No association with neck CT (HR: 1.07, 95% CI: 0.80; 1.43) was observed.In our study population, a similar risk of cataract with head, neck or the rest of the body CT was detected.

Purpose Polyps are a common finding on colonoscopy procedures. After completing polypectomy, patients are to be followed up with endoscopy. The purpose of the study was to assess the adherence of gastroenterologists to international post-polypectomy guidelines. Methods Israeli gastroenterologists answered a questionnaire, consisting of 30 items, regarding the recommendation for post-polypectomy surveillance following colonoscopy. Results One hundred and twelve gastroenterologists, representing 23% of the total number of Israeli gastroenterologists, participated in this study, by responding to the web-based questionnaire (mean age is 47 ± 10 years, males, 74 (66%)). From the total responses, 57.4% were compatible with the updated European post-polypectomy guidelines. The recommendations appeared remarkably inappropriate when applied to polyps that were identified as having low-risk tubular adenoma, tubular adenoma with high-grade dysplasia, and small serrated adenoma. In 37.2% of questionnaires, the recommended time to follow-up colonoscopy was shorter than currently stated in the guidelines. The appropriate polypectomy technique was chosen by 62% of the responses. Gastroenterologists younger than 45 years of age adhered more strongly to the international guidelines, particularly in cases of piecemeal polypectomy or high-risk adenoma polypectomy. Conclusions Gastroenterologists follow the clinical guidelines for post-polypectomy surveillance intervals partially. 57.4% of the recommendations were compatible with the guidelines, whereas 37% of the recommendations were for shorter interval.

Background and Aim: Hijab pins ingestion is increasing. Some women hold the pin between their teeth while arranging the Hijab and the inadvertent ingestion of the pin can be the result of any careless movements. The aims of our study were to investigate the clinical outcomes of patients who underwent endoscopic pin removal via gastroscopy as opposed to patients who were treated conservatively with clinical observation, and to compare clinical and endoscopic data pertaining to patients who underwent early versus late gastroscopy.Methods: Muslim women hospitalized in a tertiary hospital from 2005-2015 due to ingestion of Hijab pin ingestion were included. Patients who underwent gastroscopy during 12 hours from the time of admission to Emergency Room (ER) were included in the “early” gastroscopy group, while endoscopy performed at a later time defined the “late” gastroscopy group.Results: During the study period 37 women were included. Twenty four patients (65%, mean age 20 ± 8.9) underwent gastroscopy; and thirteen (35%, mean age 19.9 ± 1.6) were hospitalized for observation. Six patients (25%) had normal gastroscopy; by 8 patients (33%) the pin was located in the antrum, 6 (25%) body, 2 (8.3%) and 1 (4.1%) in the duodenum. Fifteen patients underwent early gastroscopy and nine underwent late gastroscopy. The Duration of hospitalization was significantly shorter among patients who underwent early gastroscopy 1-day (1, 1) median, (IQR) compared with 2 days (1, 3) p < 0.02. Severe complications were found in one patient (2.7%) with stomach perforation which required surgery.Conclusion: Most pins will pass spontaneously, however severe complication may arise inadvertent Hijab pin ingestion. Early gastroscopy shortens the hospital stay.

Type 2 diabetes mellitus (T2DM) is a risk factor for mortality after acute myocardial infarction (AMI). We studied the impact of T2DM related to sex and age on post-AMI long-term mortality.A retrospective study included post-AMI patients. Data were obtained from electronic medical records. We defined the study groups by T2DM, stratified by age-sex.up-to-10 years post-discharge all-cause mortality.16,168 patients were analyzed, 40.3% had T2DM. Ten-year mortality rates were 50.3% with T2DM vs. 33.1% without T2DM, adjHR = 1.622 (p 0.001). Females (adjHR = 1.085, p = 0.052) and increased age (adjHR = 1.056 for one-year increase, p 0.001) were associated with a higher risk of mortality (borderline statistical significance for sex). The relationship between T2DM and mortality was stronger in females than in males at 50 and 60-69 years (p-for-interaction 0.025 and 0.009 respectively), but not for other age groups.The study implies heterogeneity in the impact of T2DM on mortality of post-AMI patients, being greater among young patients, particularly females, and no significant impact in octogenarians. That implies that young women with T2DM should have advanced measures for early detection of coronary artery disease and tight control of cardiovascular risk factors to lower the propensity to develop AMI.

Little data exist to support concerns over bone turnover suppression during prolonged oral bisphosphonate treatment and on consequences of the recommended "drug holiday." This study was performed to assess bone resorption rates in postmenopausal osteoporotic women on prolonged oral bisphosphonate treatment and in response to switching to "drug holiday" intravenous bisphosphonate, or continuation of oral bisphosphonates.The frequency distribution of the bone resorption marker urinary deoxypyridinoline crosslinks (uDPD), was obtained retrospectively from 211 osteoporotic women attended at an academic hospital endocrine clinic, treated for2 years with oral bisphosphonates. In some patients, uDPD was re-assessed following modification or continuation of treatment.The mean duration of oral bisphosphonates treatment was 7.2 ± 3.1 years. uDPD was within reference range for premenopausal women in 61.6% of the patients, below in 7.6% of the patients, and above upper limit in 30.8%. uDPD decreased significantly following intravenous zoledronic acid, increased significantly during "drug holiday," and slightly decreased in those continued on oral bisphosphonate treatment.In this real-world study, the majority of women on prolonged oral bisphosphonates maintained bone resorption rates within the normal reference range for premenopausal women. The likelihood for inadequate suppression was considerably greater than that of over-suppression. Implementing a "drug holiday" resulted in a marked increase in bone resorption rates. Additional studies should explore the potential role of bone turnover markers in the evaluation of patients on prolonged oral bisphosphonates and during "drug holiday" in different settings and using additional markers.BMD = bone mineral density; IQR = interquartile range; uDPD = urinary deoxypyridinoline crosslinks.

Patient function is a risk factor of mortality following acute myocardial infarction (AMI). Norton scale (NS) was originally developed to estimate the risk for pressure ulcers. It contains 5 domains: mental condition, physical condition, mobility, activity in daily living and incontinence.To evaluate NS as long-term prognostic marker following AMI.A retrospective study based on computerized medical records of AMI patient hospitalized in a tertiary medical center in 2004-2012. NS scores and patients' characteristics were collected from computerized databases. The primary outcome was all-cause long-term (up-to 10-years) mortality.Overall 6964 patients were included; mean age 67.3±14.1years, 68.1% males. Mean NS score was 17.8±3; of which 21.1% had low-NS (≤16). Patients with low-NS had increased prevalence of hypertension, diabetes and renal disease, 3-vessel coronary artery disease, more often Non ST-Elevation Myocardial Infarction (NSTEMI) and in-hospital complications. Throughout the follow-up period cumulative mortality rate in patients with low- and high-NS groups were 97.3% and 43% respectively (AdjHR 1.66; 95% CI: 1.521-1.826; p0.001). Furthermore, a reduction in one point in the NS score inversely associated with increased risk for mortality (AdjHR 1.10; 95% CI: 1.12-1.22; p0.001).NS is an independent long-term prognostic marker for all-cause mortality in hospital survivors with a gradual "dose-response" effect. This data emphasizes the importance prognostic implication of the general functional status on the prognosis of AMI patients.

Background Liver cirrhosis (LC) is a common disease with varied primary causes and ethnic disparities. We aimed to determine the frequency, clinical characteristics, and outcomes of liver cirrhosis among the Arabs population in southern Israel.Methods This retrospective and follow-up study enrolled all patients diagnosed with liver cirrhosis at the gastroenterology and hepatology department or the internal medicine ward. Patient records were reviewed for demographic, clinical data, and mortality. Clinical primary outcomes were defined as death, hepatocellular carcinoma or liver transplantation.Results We included 820 patients 69 (8.4%) Arabs and 752 (91.6%) Jewish patients. Incidence of cirrhosis was much lower among Arabs patients, 5-10/100,000/year, compared with 20-40/100,000 per year in Jewish patients. Age at diagnosis was 42.6±16.9 years among Bedouins compared to 61±13 years (p

Objectives To determine the levels of endogenous α1-antitrypsin in the perilymph of patients undergoing cochlear implant (CI), and its reverse association with the severity of hearing loss. Study design Retrospective study. Setting Tertiary care university hospital. Participants The study includes 38 patients undergoing CI surgery, 11 patients diagnosed with congenital deafness and 27 non-congenital deafness, eight patients diagnosed with moderate hearing loss (N = 8; PTA = 70 dB), severe hearing loss (N = 11; PTA 70-90 dB) and profound hearing loss (N = 19; PTA > 90 dB). Main outcome and measure 1 to 12 μL perilymphatic fluids were collected by micropipette. α1-antitrypsin levels were determined, and current and historic audiological parameters were obtained. Results The congenital and non-congenital group exhibited AAT concentrations of 2.5 ± 1.9 × 106 LFQ and 3.2 ± 1.2 × 106 LFQ, respectively (mean ± SD; P = .38). Mean levels of α1-antitrypsin in the perilymph fluid within the moderate group was 3.64 × 106 ± 2.1 × 106 LFQ vs 3.5 × 106 ± 1.2 × 106 in severe hearing loss (P = .81) and 2.4 × 106 ± 1.1 × 106 LFQ in the profound hearings loss group (P = .06). The difference in levels of AAT in samples from the severe hearings loss group vs the profound hearings loss group reached statistical significance (P = .04). Conclusion Insufficiency in α1-antitrypsin levels in the perilymph fluid of the inner ear appears to display a relationship with the severity of hearing loss. The prospect of introducing clinical-grade plasma-purified α1-antitrypsin directly onto the site of cochlear injury deserves thorough investigation.

Bisphosphonates are the mainstay of the treatment of Paget’s disease of bone (PDB). Clinical practice guidelines recommend treatment with intravenous zoledronic acid or high-dose oral nitrogen bisphosphonates (N-BPs). We present our long-term experience treating PDB patients with lower than recommended oral doses of N-BPs, equivalent to once-weekly doses used for treating osteoporosis. PDB patients were seen, between 1990 and 2015 at the endocrine clinic of an academic medical center. Diagnosis was established according to accepted criteria. Patients were initially treated with alendronate 70 mg/week or risedronate 35 mg/week. Whenever the initial dose failed to produce remission, the dosage was increased to twice a week the respective dose. Patients were followed for a mean of 11.9 years (range: 1.7–24.8). Out of 96 treatment courses with N-BPs, 89% were with alendronate and 11% with risedronate. Remission was achieved in 84% of the courses with alendronate 70 mg/week. 90% of those who did not achieve remission subsequently responded to 140 mg/week. Out of the 8 treatment courses with risedronate 35 mg/week, 87% achieved remission, and the 2 patients who did not achieve remission subsequently responded to 70 mg/week. The median duration of remissions following 3-4 months courses of alendronate 70 mg/week or risedronate 35 mg/week was 8.8 months (IQR: 5.5, 14.8). In a large proportion of “real world” PDB patients, remission can be achieved with once-weekly, “osteoporosis doses” of alendronate or risedronate.

Background: Systemic complications of intravitreal anti-vascular endothelial growth factor agents are relatively uncommon but highly significant. Objectives: Primary objective: To assess the risk for thromboembolic events following intravitreal bevacizumab injection in neovascular age-related macular degeneration patients by a large population-based study. Secondary objective: To analyze the association between injection frequency and the risk for thromboembolic events, the time interval between the injection and the thromboembolic events, and the influence of chronic diseases on complications rate. Design: A retrospective cohort study. Methods: Consecutive neovascular age-related macular degeneration patients receiving intravitreal bevacizumab at Soroka University Medical Center from December 2005 to December 2013 were included. Thromboembolic events analyzed included acute coronary syndrome, acute myocardial infarction, stroke, deep vein thrombosis, and pulmonary embolism. The thromboembolic event rate was compared 2 years prior and 2 years after the initial intravitreal bevacizumab injection. Results: A total of 2102 patients were included. Acute coronary syndrome and stroke rate were higher 2 years after intravitreal bevacizumab (p = 0.03 and p = 0.01, respectively). No statistical significant difference was found for the rest of thromboembolic events. Patients older than 80 years and patients receiving less than six intravitreal bevacizumab injections were more likely to experience stroke. Patients with known cardiovascular risk factors before starting injections did not develop significant more thromboembolic events. Conclusion: In our study population, patients treated with intravitreal bevacizumab were significantly more likely to experience stroke during 2 years after first injection.

Inflammatory bowel disease (IBD) prevalence is increasing among Bedouin Arabs in Israel. This population is known to have a high rate of consanguinity. NOD2/CARD15 mutations are well-studied in IBD.To investigate the frequency of NOD2/CARD15 mutations in IBD Bedouin patients and their relevance to disease phenotype.The IBD-Arab cohort in southern Israel included 68 patients, of which 25 Crohn's disease (CD) patients and 25 ulcerative colitis (UC) patients consented to participate (72%). Blood samples were obtained from all participants who were genotyped for NOD2/CARD15 variants Arg702Trp, Gly908Arg, and Leu1007fsinsC.The NOD2/CARD15 mutation frequency was higher in Crohn's disease than in ulcerative colitis patients. Carrier frequency for the Gly908Arg mutation in CD and UC patients was 8/25 (32%) and 3/25 (12%), respectively (P = 0.08). Neither the Arg702Trp nor Leu1007fsinsC mutation was found in our cohort. No homozygous/compound heterozygote mutations were found. Genotype-phenotype analysis revealed that CD patients carrying the Gly908Arg mutation were younger at diagnosis, 22.8 ± 4.5 vs. 28.82 ± 9.1 years (P = 0.04). All carriers were males, compared with 41.2% in non-carriers (P = 0.005). NOD2/CARD15 mutation carriers with UC were older, 67.0 ± 24.5 years compared with 41.2 ± 12.3 years (P = 0.006). No other associations regarding disease localization or other clinical parameter were found.The frequency of NOD2/CARD15 gene mutations is high in CD and UC among Bedouin Arab IBD patients and is associated with younger age at onset in CD and male gender.

Background Serological markers used for diagnostic purposes and disease stratification in inflammatory bowel disease. We aimed to investigate the frequency of ASCA and ANCA among Arab Bedouin IBD patients and its relationship to disease phenotype and course. Methods From cohort of 68, 25 Crohn’s disease (CD) and 25 Ulcerative colitis (UC) patients were recruited (72%). ASCA IgG was determined by ELISA assay. Immunofluorescence analysis of ANCA was performed. Results The IgG ASCA was detected in 13 (52%) of the CD patients and in three (12%) UC patients. The prevalence of ANCA among UC patients was positive with 76%, sub-grouped, atypical ANCA in 9 patients (36%), pANCA in six patients (24%) and cANCA in 4 patients (16%). The detection of ASCA among CD patients was found not to be a reliable predictor of young age at diagnosis, gender, ileal involvement, anti-TNF treatment or surgery. UC patients with positive ANCA were younger, mean age 40.2 ± 11.9 compared with 57.3 ± 21.2 (p = 0.03), and diagnosed at a younger age, 29.2 ± 11.8 compared with 43.5 ± 15.3 (p = 0.05). Conclusion The frequency of ASCA among Bedouin CD patients and ANCA among UC patients was high, however ASCA was not found to have a predictive value for disease phenotype or course. Positive ANCA in UC patients was predictive for younger age and age at diagnosis.

INTRODUCTION The Israel Defense Forces (IDF), as well as many other armies, faces major challenges in balancing the need to protect soldiers from harm while not impeding their ability to fight. Eye protections available in the IDF are underused, for reasons that are as yet unclear. In this study, we aim to gain a better understanding of the influence of eye protection currently in use in the IDF on vision. MATERIALS AND METHODS In this cross-sectional study, subjects were assessed for best corrected visual acuity, contrast sensitivity, and binocular visual fields (Goldmann) in a crossover design (with and without eye protection). In addition, we established a comprehensive review on the subjective faults of the eye protection, both from personal experiences of soldiers who used them during their military service and from civilian volunteers who used them in a sterile laboratory setting. RESULTS Visual acuity, contrast sensitivity and visual fields with and without the eye protection were assessed in 25 subjects. Eye protection did not cause any statistically significant change in visual acuity. However, the eye protection caused a statistically significant decrease in visual fields in all quadrants and in both isopters used. CONCLUSIONS Significant restriction of the visual field can pose a major challenge for soldiers on the battlefield. The use of eye protection with wider lenses or no frame should be considered. Education and instruction should focus on increasing awareness among commanders and soldiers of the benefits of eye protection and fostering trust in the technology's capabilities. In parallel, it is crucial to educate soldiers about its disadvantages, and how such disadvantages can be overcome. We stipulate the findings to the standard IDF goggle and might not apply to other designs.

ObjectiveTo identify the clinical characteristics and genetic etiology of a family affected with hereditary spastic paraplegia (HSP).MethodsClinical, genetic, and functional analyses involving genome-wide linkage coupled to whole-exome sequencing in a consanguineous family with complicated HSP.ResultsA homozygous missense mutation was identified in the ACO2 gene (c.1240T>G p.Phe414Val) that segregated with HSP complicated by intellectual disability and microcephaly. Lymphoblastoid cell lines of homozygous carrier patients revealed significantly decreased activity of the mitochondrial aconitase enzyme and defective mitochondrial respiration. ACO2 encodes mitochondrial aconitase, an essential enzyme in the Krebs cycle. Recessive mutations in this gene have been previously associated with cerebellar ataxia.ConclusionsOur findings nominate ACO2 as a disease-causing gene for autosomal recessive complicated HSP and provide further support for the central role of mitochondrial defects in the pathogenesis of HSP.

Data on the various aspects of brucellosis in children living in southern Israel are missing.Our aim was to study the epidemiological, microbiological, diagnostic, clinical, therapeutic and outcome features of brucellosis in children19 years of age in southern Israel during 2005-2011.The study population included all patients hospitalized with a diagnosis of brucellosis, established according to a clinical presentation compatible with brucellosis+presence of Brucella bacteremia (BB).A total of 128 (50.8%) of 252 patients admitted with a diagnosis of brucellosis had BB (all with Brucella melitensis). All patients were of Muslim Bedouin ethnicity. The mean incidence of BB in southern Israel was 16 cases/100,000 Bedouin, with no significant changes during the study period. Overall duration of symptoms before diagnosis was 10.1±10.9 days. Fever at diagnosis was recorded in20% of the patients. The most frequent symptoms were arthralgia (61.7%), weakness (32.8%), gastrointestinal disturbances (27.3%), myalgia (25%), and headache (18.8%). The main clinical findings included monoarthritis (36.7%), hepatosplenomegaly (25%), lymphadenopathy (17.2%), heart murmur (11.7%), and skin rash (9.4%), respectively. Anemia, leukopenia, thrombocytopenia, and pancytopenia were reported in 17.6%, 29.6%, 12.8%, and 2.3% of the patients, respectively. Twenty-nine (30.5%) patients with BB had serum agglutinin titers ≤1/160 (13, 13.7%%, had titers1/160). Twenty-seven (93%) of the 29 patients aged 0-4 years were treated with gentamicin and trimethoprim-sulfamethoxazole; a total of 77 (60.2%) patients received gentamicin and doxycycline.Childhood brucellosis remains an important public health problem in southern Israel. BB was diagnosed in50% of the children with brucellosis, and B. melitensis was identified in all cases. Arthralgia, weakness, and gastrointestinal complaints were the most common symptoms, and monoarthritis, hepatosplenomegaly, and lymphadenopathy were the most common clinical findings. A considerable number of patients with BB had undetectable/low serum agglutinin titers, suggesting insufficient reliability on serology alone in diagnosis of brucellosis.

We sought to determine the prevalence of diabetes mellitus (DM) newly diagnosed by elevated glycated hemoglobin (HbA1c) in patients undergoing percutaneous coronary intervention (PCI) and its association with 1-year clinical outcomes.We prospectively enrolled consecutive patients undergoing PCI (2011-2013). HbA1c levels were assessed during the index hospitalization and newly diagnosed DM was defined as HbA1c≥6.5% in the absence of the previous diagnosis. The primary outcome was MACCE (Major Adverse Cerebro- and Cardiovascular Events) defined as death, stroke, PCI or acute myocardial infarction at 1year.Diabetes was previously diagnosed in 391 (34%) patients (DM group), 221 (19%) had newly diagnosed DM based on the HbA1c level and 539 (47%) did not have diabetes (Non-DM). In DM group HbA1c was 7.80±1.36% as compared with 7.62±1.30% in patients with newly diagnosed DM (p0.001). These patients were younger (62.0±11.3years) compared to DM (67.9±10.4years) and non-DM (63.7±13.0) patients, p0.001. 1-year MACCE rates were 14.8%, 19.5% and 27.96% in the non-DM, newly diagnosed DM and DM groups, respectively (p0.001). Multivariate analysis showed that compared to non-DM, the adjusted one-year hazard ratios for MACCE were 1.75 and 1.40 in patients with known DM and newly diagnosed DM, respectively (p0.05 for both).Newly diagnosed DM based on peri-procedural HbA1c is common and associated with increased short and long term risk for adverse outcomes. Our results may warrant routine screening for DM in all patients undergoing PCI.

Specialized training of medical teams for chemical warfare agent (CWA) events is important to save lives. We aimed to evaluate the retention of knowledge (ROK) and self-perceived competency (SPC) of military medical personnel in delivering treatment during CWA events.A questionnaire and a multiple-choice examination were sent to military physicians and paramedics, evaluating their CWA, ROK, and SPC (study group [SG]). Their assessment was compared to medical personnel immediately post training (reference group [RG]). SG was subdivided into two groups: G1 ≤ 1 year and G21 year, past training.Overall, 135 participants responded (35-RG, 65% physicians). Self-reported ROK and SPC were significantly higher in RG compared to SG and in G1 compared to G2. Test scores were higher in RG compared to SG, but similar in G1 and G2 groups. SPC was lower compared to ROK in the entire cohort and subgroups. A moderate correlation was found between the self-and test-assessed scores (Pearson correlation coefficient 0.45, p0.001). Physicians received significantly (p = 0.01) higher test scores in RG compared with paramedics.ROK and SPC among military medical personnel for treatment of CWA casualties deteriorate significantly as early as 1 year post training, SPCROK. Thus, we recommend CWA refresher training at least every year.

Raised plasma troponin, a diagnostic marker for myocardial infarction, usually occurs after cardiac surgery, leading to difficulties in diagnosing postoperative myocardial infarction. To ascertain whether the same processes influence troponin elevation in both conditions, a literature search was performed for plasma troponin elimination curves after myocardial infarction, myocardial infarction with reperfusion, and cardiac surgery. From 70 studies, 11 curves using the Stratus immunoassay kit were analyzed: 5 post-cardiac surgery (412 patients), 2 after myocardial infarction with reperfusion (169 patients), and 4 after myocardial infarction (640 patients). For each group, a new plot was formulated from the mean troponin level at each time interval. While the up-slope of the cardiac surgery curve was much steeper than that of myocardial infarction, resembling that of myocardial infarction with reperfusion, its down-slope was significantly more gentle than that of both other groups (−0.91 vs −5.31, t = 3.47, df = 8, p < 0.01). This suggests that postoperative troponin elevation involves enhanced cell permeability as seen after ischemia reperfusion rather than permanent cellular damage. The gentler down-slope may point to surgery-induced impaired troponin removal from the circulation. Due to the different mechanisms proposed, implications from post-myocardial infarction troponin levels may not be conferred on post-cardiac surgery patients.

Inflammatory bowel disease (IBD) has been associated with genetic and environmental factors, including urban living. IBD was rare in the Israeli Bedouin community 30 years ago. Over recent decades, a large proportion of this community has undergone a transition from a nomadic to a western lifestyle. Our aim was to carry out an updated evaluation of the clinical and epidemiological features of IBD in the Bedouin sector of southern Israel.All Bedouin patients with a known diagnosis of Crohn's disease (CD) or ulcerative colitis (UC) were included in the retrospective study.The cohort included 31 CD patients and 31 UC patients. The mean age of the patients at diagnosis was 29±10.9 and 35±17.5 years for CD and UC, respectively. The prevalence rate for CD was 15.5/100,000 and the incidence rate was 0.8-3.55/100,000. Fourteen of the CD patients (45%) had ileal disease and 64.5% had inflammatory disease behavior according to the Montreal classification. Eleven of the CD patients (35%) were treated with anti-TNF-α and 26% had undergone surgery. Over the previous decade, the prevalence of UC was 14/100,000 and the incidence was 0.5-2.39/100,000. Eighteen UC patients (58%) had left-sided colitis. Three (9.7%) had undergone total colectomy for severe disease.We found an increased prevalence of IBD in the Bedouin population, associated with their change in lifestyle over previous decades. However, the prevalence is still markedly lower than that in other population groups. A high percentage of patients were treated with anti-TNF-α and/or surgery.

Introduction: The reported rate of Diabetes Mellitus (DM) in patients undergoing Percutaneous Coronary Intervention (PCI) is 30%-40%. In 2008, the International Expert Committee recommended diabetes diagnosis by HbA1c level ≥6.5%. Our aim was to determine the prevalence of previously undiagnosed DM defined by elevated HbA1c in patients undergoing PCI and its association with 1-year clinical outcomes. Methods: Consecutive patients undergoing PCI in a large tertiary teaching hospital were enrolled (2011-2013). HbA1c was measured before angiography. The primary outcome was 1-year Major Adverse Cardio- and Cerebrovascular Event (MACCE) defined as death, stroke, PCI or acute MI. Secondary outcomes included short term mortality. Results: 1313 patients were enrolled (795 with ACS). DM was previously known in 528 (40.2%) patients, 232 (17.7%) had Undiagnosed DM (UDM) based on the HbA1c ≥6.5% and 553 (42.1%) did not have diabetes (Non-DM). In patients with DM HbA1c was 8.0±1.8% as compared 7.6±1.4% in patients UDM (p=0.003). UDM patients were younger (64±11) compared to DM (69±11) and non-DM (64.5±13), p Conclusions: Pre-procedure HbA1c testing leads to the diagnosis of previously unknown DM in a large subgroup of patients undergoing PCI. These patients represent an intermediate group as their short term mortality resembles that of patients with DM while 1-year MACCE rates are similar to non-DM patients, possibly reflecting early detection and treatment. Our findings support routine screening for DM in all patients undergoing PCI.

Approximately 520,000 residents (30 % Bedouins) inhabit the Negev region of southern Israel. Despite the geographical proximity, Bedouins differ from Jews demographically and socio-economically. To evaluate the ethnic disparities in emergency department (ED) utilization patterns in this population-based observational retrospective cohort study, individual data regarding 93,338 visits to the ED throughout 2007–2009 (9 months) were obtained. Demographic data were obtained from the Central Bureau of Statistics. The age- and gender-adjusted annual rates of ED visits were: 31.1 and 23 per 100 residents for Bedouins and Jews, respectively (P

The incidence and prevalence of coronary heart disease (CHD) among Bedouins living in the Negev region were very low until the 1960s. During the past 50 years this pattern has changed: in parallel to the changes in lifestyle and nutrition in the Bedouin population, a rapid increase in incidence and mortality from CHD occurred. The relationship between the rise in CHD incidence and the degree of urbanization in this population has not been investigated to date. The study hypothesis was that the prevalence of risk factors and the outcome of myocardial infarction in Bedouins differ between those settled in permanent villages and those remaining in unrecognized villages.To compare the prevalence of cardiovascular risk factors, clinical characteristics, and in-hospital management of a first acute myocardial infarction (AMI) in two Bedouin groups: those residing in permanent villages versus those residing in unrecognized villages.We conducted a retrospective analysis of in-hospital data of 352 patients admitted with a first AMI during the period 1997-2003 to Soroka Medical Center, the only medical facility in the region.There were no differences between the two groups regarding the major cardiovascular risk factors and outcome. A relatively greater number of patients from urban areas underwent catheterization of any sort during their hospitalization (primary, rescue, and risk stratification; P = 0.038). No significant difference was found between the two groups in the type of catheterization performed (P = 0.279).We found no differences in the clinical characteristics and in-hospital management of patients with AMI between Bedouins residing in permanent villages versus unrecognized villages.